Christmas in Hospital and the challenges that lay ahead

It seems a gloomy picture heading into Christmas. The temperatures are dropping, poverty is looming, and the rail strikes are gathering.

No amount of good cheer is going to make things better. It’ll be a grim Christmas for many and for those older people with physical and mental ill health, the prospect could be even worse.

Yes, I know we’re not supposed to use the words of abandonment but that must be exactly what it feels like. Well, at least it’s warm and there’ll be a Christmas lunch of sorts, I hear you say. Not if you’re lying on the floor in the cold for hours waiting for an ambulance or sitting in an ambulance for hours outside A&E or even in a hospital corridor.

Moreover, on December 6th, in the lead up to Christmas, all the national press reported the findings that 1 in 7 people are denied GP appointments whilst others wait over a month.

Now, we all know that everyone in the health and care public sector work their socks off. We take that for granted and that’s why we clapped during covid. But nothing has changed since that clapping, so what’s the problem?

Firstly, what was supposed to be the clarion cry for more joined up services, The integrated Care Systems, has so far largely ignored primary and community-based services across health and social care. The shared responsibility for the health of our local communities is still largely missing and this is what those local areas that are planning to base their systems properly and fully on local place are striving to achieve.

My recent experience as a Non-Executive Director on a Hospital Trust suggests that this missed opportunity can still be remedied. I believe this is primarily because although, across health and social care we all have shared values and shared accountability for the health and wellbeing of our local people, we do not always articulate this or behave as though this is the case.

In my Trust there was no shortage of wonderful people, excellent services and well-run flow within the hospital but a feeling that the responsibility for the full flow into and out of hospital across into primary care, let alone social care did not lie with them. This was despite best efforts and a deeply caring acute trust.

Despite an excellent follow up report ‘Next Steps for integrating primary Care: Fuller Stocktake report’ too little has happened in practise, social work and social care, an essential part of the safety network is all but invisible. I want to suggest it’s time for a follow up stock take Report on Social Work and Social Care.

Secondly, Sir David Nicolson recently declared (HSJ November 2022) that most data collected about hospital discharges by NHS England is “useless” and biased against social care. Sir David was CE of the NHS from 2006 – 2013 and NHS England until 2014 went on to say that “almost all the data is designed to show how bad social care is.”

If the data on the “right to reside” in hospital is wholly useless when trying to improve discharge rates, grouping the data into pathways according to the type of services people need on discharge can and should make a huge difference. We still won’t have the complete picture, however, until the data includes social care data.

The irony is that this is perfectly possible and yet many Electronic Care Records are not yet up to speed with this. Sir David also said, “What the NHSE haven’t done is modelled the behaviour that is required at a local level.” I would add it must include social care data and of course this is what Place based services are all about.

Sir David is right - the data is almost worthless other than for straight up and down counting, and I would argue further that those Trusts that are taking it on will regret it.

Local Authorities are much more experienced at commissioning care than the NHS, especially on a locality basis. They’ve been doing it effectively for over 40 years. The problem does not lie in the commissioning, it lies in the lack of funding and joined up thinking.

What is the answer then? More working together, a more joined up thinking and planning, more of a sense of this is a shared endeavour with the shared accountability for making it work. The ICBs can make this work but only if they engage fully with local partners and local authorities. There are enough freedoms and flexibilities to do this already. Place based approaches do work, together with getting closer to local community resources the people who use services, co-producing new models of care that maximise the input from family and friends, as well as the state.

Thirdly, the Hewitt review, is widely heralded as seeking a new way forward and we must take courage from the fact that this is effectively a cross party review. The terms announced on 6th December are encouraging, offering an opportunity to implement the ICS differently, and so could fundamentally change the way the NHS operates. Could it become the whole system, all singing all dancing place to go, where all pathways flow together across the whole primary community based and acute care systems?

There may, however, be a missing part of the jigsaw, social work and social care. Social work is integral to social care and an essential part of the safety network for vulnerable people.